Socioeconomic Aspects of Proton Therapy

Charles B. Simone, II, MD
Abramson Cancer Center of the University of Pennsylvania
Last Modified: October 31, 2007

The following is a summary of a presentation by Timothy Williams, MD from a panel session at the ASTRO 2007 Annual Meeting.

The last two decades have seen an era of unparalleled technical developments in the field of radiation oncology. Three-dimensional conformal radiation therapy and intensity modulated radiation therapy (IMRT) have become the standard of care for the treatment of a wide variety of tumors. More recently, much interest and excitement has been generated for proton beam therapy.

Proton therapy allows for a theoretical benefit of an improved therapeutic index, the ratio of the probability of tumor control to the probability of treatment toxicity. With less entrance dose and no exit dose, protons allow for more dose to be deposited in the tumor. This could allow for higher treatment doses that could translate into improved local control and survival. Currently, there are five facilities in the United States that have operation proton beam machines, with two more projected to be operational within the next one to two years. Numerous additional facilities are contemplating the acquit ion of proton machines. However, are these $100 million dollar machines worth the cost to treating facilities and taxpayers? Those were some of the questions that Timothy Williams, MD addressed during the ASTRO Proton Therapy Panel Discussion.

To discuss the socioeconomic questions surrounding proton therapy, Dr. Williams, Present-elect of ASTRO, first discussed the economic impact that the growth of IMRT has had on the field of radiation oncology and medicine. Since 2001, Medicare Part B dollars allocated to radiation oncology has increased 97% to $1.599 billion in 2006. That figure accounts for 2.1% of all Medicare dollars, despite radiation oncologists comprising only 0.5% of physicians in the United States. IMRT accounts for over half of radiation dollars, with over $823 million in 2006. This represents the twentieth highest cost code in Medicare health delivery, up from forty-fourth in 2001. Dr. Williams questions whether such trends could be sustained and cautioned that rising radiation oncology Medicare dollars will be meet with increasing scrutiny in reimbursement within the field.

Based on the approximately 1.4 million patients in America diagnosed with cancer each year, and the 60% of patients who receive radiation therapy, proton therapy could theoretically benefit approximately 250,000 patients after an assumption that Dr. Williams provided that 30% of patients could show a benefit from proton therapy over conventional therapy.

Reimbursement is uniformality higher for proton therapy than for other forms of radiation treatment. Dr. Williams reported that the reimbursement per fraction for proton beam therapy was approximately $1011, significantly higher than the $631 for IMRT. Additionally, estimated costs of treating prostate cancer were reported to be $50,000 with proton therapy, $35,000 with IMRT, and $15,000 with brachytherapy.

However, proposed 2008 Medicare Part A payments for the proton treatments at Massachusetts General Hospital and Loma Linda University Medical Center, the only two hospital-based facilities with operation proton beam machines, are already projected to be decreased from 2007 levels. Additionally, Midwest Proton Radiotherapy Institute at Indiana University, University of Texas M. D. Anderson Cancer Center, and University of Florida Proton Therapy Institute, the three existing free-standing proton centers, are not guaranteed Medicare Part B reimbursement. Instead, they are at the discretion of the Director, and payment could be cut or even discontinued at any time.

The larger proton machines that are currently operational in America, including machines manufactured by IBA and Hitachi, are priced between $100 and $120 million. Newer devices by Accel and Varian range in cost from $60 to $80 million. Smaller units still under development by such companies as Still River Systems are projected to cost $15 to $20 million.

There is currently little long-term data supporting the use of proton beam therapy over other forms of radiation, perhaps with the exception of ocularand skull-base tumors and pediatric malignancies. However, for vendors and therapy centers to recover operation costs, malignancies with higher incidence will also need to be treated with proton therapy. As such, proton therapy is increasingly being applied to the treatment of prostate cancer in an attempt to deliver more radiation to the prostate than could be allowed with IMRT to improve the chance of local control and overall survival, or to deliver similar doses with less treatment side effects. Although a growing body of literature suggestions a benefit, at this time there is no definitive evidence that proton therapy is superior to IMRT for the treatment of prostate cancer.

Dr. Williams warned that institutions and centers contemplating the acquisition of proton beam machines should invest in the technology for a belief in its superior clinical efficacy. However, numerous additional factors, including program differentiation, revenue generation, institutional prestige, and competitive maneuvers are likely being considered by potential buyers.

With current trends in the increasing usage and reimbursement for IMRT and proton beam therapy, radiation oncology is projected to account for $12.8 billion of the $180 billion Medicare Part B dollars allocated by the year 2020. Although predicting the future is a difficult endeavor, Dr. Williams left the audience with the question he began his discussion with....Are these current trends sustainable?

Partially funded by an unrestricted educational grant from Bristol-Myers Squibb.